Provider Demographics
NPI:1710140645
Name:NIEBRUEGGE, JOSHUA A (MD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:A
Last Name:NIEBRUEGGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:STE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-851-7423
Mailing Address - Fax:510-879-9120
Practice Address - Street 1:4550 MEMORIAL DR
Practice Address - Street 2:STE. 340
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5372
Practice Address - Country:US
Practice Address - Phone:618-257-6200
Practice Address - Fax:618-257-6679
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036127134208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036127134Medicaid
ILIL3374055Medicare PIN